When Piyush “Bobby” Jindal — the Louisiana governor and a 2016 Republican presidential hopeful — was just 24 years old, he was appointed secretary of Louisiana’s Department of Health and Hospitals (DHH).
A Rhodes scholar, the wunderkind was plucked out of his consulting job at McKinsey in 1996 by then-Gov. Mike Foster to steer the DHH out of a crisis that saw the state’s Medicaid budget jump from $1 billion to $4 billion in five years amid allegations of fraud.
Almost 20 years later, Jindal, who is poised to leave the governor’s mansion in January, is again mired in a Medicaid debacle, having been roundly criticized for his handling of a $1.6 billion budget shortfall. The state’s Legislative Fiscal Office is projecting a deficit of at least $700 million for next year, including a $335 million gap in Medicaid funding.
In a move that drew praise from right-wing pundits but the ire of many Louisiana residents, in 2013 he refused to accept some $16 billion in matching federal Medicaid funds offered under the Affordable Care Act, in spite of the state’s budget woes. Under the act’s expansion of Medicaid, at least 200,000 additional uninsured low-income Louisianans would have qualified for Medicaid.
In the run-up to his presidential campaign, Jindal has often used health care issues — including his current fight to block funding for Planned Parenthood — to buttress his conservative credentials, usually at the expense of Louisiana’s working poor, activists say.
Louisiana has a long list of poor health rankings: the third-highest HIV and syphilis rates in the nation, the fifth-highest cervical cancer rate and 12th-highest teen pregnancy rate. Meanwhile, Jindal’s conservative health agenda — built around opposition to abortion, abstinence education and health care privatization — has generated significant national criticism.
In a conservative victory often touted by Jindal at home and on the campaign trail, Louisiana was ranked the most anti-abortion state in 2015 by Americans United for Life, holding that title for five of the last seven years.
His most recent fight with Planned Parenthood began after the release of undercover videos in July claiming the organization is profiting from fetal tissue collection for scientific purposes. The organization has strongly denied any form of wrongdoing and said the videos are misleadingly edited to score political points.
In Louisiana, Planned Parenthood operates two clinics — one in New Orleans and one in Baton Rouge — neither of which has performed an abortion in over 30 years of existence. The organization says it provides services to more than 5,000 people in the state, including cervical cancer screenings, providing contraception and HIV and STD testing.
When the Jindal administration’s August attempt to cut funding fell short with a federal judge, the DHH filed a separate request, citing a 2013 settlement at a Texas Planned Parenthood clinic that went unreported to the state, allegedly breaking state Medicaid code. DHH Secretary Kathy Kliebert claimed other clinics could handle Planned Parenthood patient runoff.
“This is an atrocity,” state Rep. Patricia Smith, D-Baton Rouge, said of the move. “Clinics wouldn’t be able to handle the influx … They’re stretched to the limit already.”
‘This is an atrocity. Clinics wouldn’t be able to handle the influx … They’re stretched to the limit already.’
state representative, D-Baton Rouge
The controversy is just the latest in a long string of conservative policies on women’s health pushed by Jindal and legislators in Louisiana — both Republican and Democratic. In 2014 a bill that requires that information on the supposed mental health effects of abortion be distributed to women seeking the procedure was passed, along with Jindal-endorsed House Bill 388, which mandates that the state’s five abortion clinics have admitting privileges at a hospital within 30 miles, a requirement that clinic operators say would effectively shut them down.
HB388, sponsored by Democrat Katrina Jackson along with 50 co-authors, was modeled in part on the 2013 Texas regulation that has so far shuttered 22 of the 41 clinics there. The Louisiana law, which was written in concert with two anti-abortion organizations, clarifies that existing “informed consent” procedures — including a pamphlet depicting fetal development, an enforced 24-hour waiting period for the patient and information on the long-term risks of an abortion — must be administered to all women seeking the procedure, whether administered surgically or with pharmaceuticals.
To date, HB388 has been blocked from implementation by a federal court injunction, and all five of the state’s clinics remain open. But Jessie Nieblas, a co-founder of the New Orleans Abortion Fund, a nonprofit that provides financial assistance for low-income women seeking abortions, said that the law’s passage has nonetheless had an effect on Louisiana’s women.
“All of these attacks really do contribute to this culture of stigma and fear around seeking an abortion,” she said. “We’ve seen some people wonder if it’s still legal, wonder if there is going to be violent protesters at the clinics.”
Nieblas said that since April 2013, her organization has provided assistance to over 400 women across Louisiana and in neighboring Mississippi. According to survey data collected by the organization, the average age of its aid recipients is 26. About 70 percent already have children, and 1 in 5 is Catholic.
“Abortion can’t be separate from other portions of people lives. It’s related to education, income, equal pay, access to primary care … All these other issues go into whether or not someone makes a decision to have an abortion,” she said.
A recent study by The Associated Press found that Louisiana was one of only two states where abortions have increased in recent years, rising 12 percent from 2010 to 2014.
Undercutting sex education
Jindal has built a reputation as a staunch promoter of abstinence-only sexual education programs in schools, declaring in-depth discussions about sexual health are best left to families.
“There is a religious contingency in this state that says it’s the parents’ responsibility to teach their kids about this stuff,” said Cindy Bishop, a representative of the Louisiana School–based Health Alliance, which receives state grants to provide preventive and mental health care to low-income students. “They’re not doing it, obviously, because the children are getting pregnant and we have very high STD rates.”
She said Louisiana laws prevent school-based clinics from distributing or discussing contraception with students under any circumstance. “Even if we have a girl that comes in and says, ‘I’m 15, and I’ve already had two kids. How do I stop from getting pregnant?’ we are not allowed to discuss contraceptives.”
Louisiana is one of 27 states that do not mandate any substantive sexual health education in school. But the state provides curriculum support to schools through the Governor’s Abstinence Education Program, which focuses on abstinence until marriage and includes claims that condoms are on average only 85 percent effective against pregnancy.
State officials note that local school districts are able to build more comprehensive sex education programs on their own. In reality, though, building more robust programs is difficult at cash- and resource-strapped schools and can still draw political opposition.
“Many [teachers and administrators] are not aware of the sex education laws in Louisiana,” said Rheneisha Robertson, the chief operating officer of the Institute of Women and Ethnic Studies, a health education and advocacy nonprofit that teaches HIV- and teen-pregnancy-prevention programs in New Orleans schools. “They are not aware of what can and cannot be taught.”
Earlier this year, state Rep. Wesley Bishop, D-New Orleans, proposed two bills that would mandate comprehensive sex education and allow schools to survey students on risky sexual behavior. Even though the measures applied only to schools in New Orleans, the state legislature voted it down.
He said that while many Republican representatives admitted in private that they supported his bills, they could not “bring that vote home with them.” But he’s optimistic he can get legislation passed once a new governor comes into office next year, “as opposed to a governor that will put his head in the sand and act like there is no need to treat this,” he said.
Medicaid, private hospitals
One of the reforms Jindal touted as governor has been privatization of the state’s Medicaid program in 2012. Bayou Health, as the new Medicaid scheme is called, outsources management of the state’s Medicaid to five private insurers and allows beneficiaries to choose their network provider. The DHH said that the switch to a managed care system, which it said allows for more preventive care services under Medicaid, has helped curb annual increases in costs to the state from 5 to 7 percent each year to just 1 to 3 percent.
However, it is unclear if gains have been made — or losses prevented — in terms of quality and access to care under the new system.
“Managed care is supposed to be about preventive medicine, but we really end up neglecting the most vulnerable population,” said Mary-Patricia Wray, the communications director for state Rep. John Bel Edwards, a Democratic candidate for governor.
Edwards has sponsored several failed bills, including one earlier this year, that would have expanded Medicaid eligibility across the state, reversing Jindal’s refusal of additional federal Medicaid dollars under the Affordable Care Act — one of his most controversial policy decisions.
A 2013 report by the DHH stated that by not expanding Medicaid, “only” 214,000 people, or 34 percent of the currently uninsured population, would remain without insurance.
“Medicaid is a stigmatized terminology and, for Republicans and Democrats alike, without public support for the truth — which is that this is a move that would help working people in our state — it is easy for it fall prey to the kind of stereotypes that it’s a handout,” said Wray.
At the same time that Jindal has privatized Medicaid and refused federal assistance, he has also orchestrated a vast privatization experiment with nine of the state’s public hospitals, including the new $1.1 billion hospital recently opened in New Orleans, replacing Charity Hospital, closed since Hurricane Katrina.
The move is a major shift in Louisiana’s unique system, one of the few publicly managed safety-net hospital chains in the country. The new system revolves around a complicated leasing scheme involving the state, Louisiana State University medical schools and private hospital operators like LCMC Health. The financing supporting the deals has seen numerous challenges and reversals, including a 2013 rejection from the federal Medicaid body and concerns over the no-bid contract award process.
“Financing is always a risk,” said Don Gregory, a health care research consultant and a former Medicaid director of Louisiana, said of privatization models. “The safety-net model has its challenges. You have to have the state match, and it’s always difficult for states because it is competing with prisons and highways and schools.”